Who, What, Where, When, Why, & How to Order Neuroskeletal Diagnostic Testing!!!!!!

Let's take a brief" look at the philosophies toward diagnostic testing and patient care of the average medical doctor and compare them to those of the average chi­ropractor. The approach to patient care of the average MD is diagnos­tics, diagnostics, diag­nostics, followed by very little treatment—a pill or surgery. This approach is acceptable to insurers, as long as the diagnostic tests are deemed medically necessary. The approach of the average DC to patient care is treatment, treatment, treatment, after employing very little diagnostics. WHY? Because DCs haven't been adequately taught how they can support the care that they deliver through the effective use of diagnostic testing. We already know that, in most cases, the chiropractic care is superior to the other methods of treatment, such as taking a pill or per­forming surgery before exhausting the other available alternatives. So why not support your superior form of healthcare with all of the modern diag­nostic tools that are available to you? These tools can assist you in becoming a better doctor—the best doctor that you possibly can be. This is what your patients deserve. There are a number of diagnostic procedures that can effectively be added into the standard chiropractic treatment protocols. The diagnostic procedures that I am referring to are Nerve Conduction Velocities (NCV). Somatosensory Evoked Potentials (SSEP), Der-matomal Evoked Potentials (DEP), and Spinal Ultrasound. These are all non-invasive, valid, and reliable diag- nostic tests. NCV, SSEP, and DEP are tests per­formed to record and study the electrical activi­ty of the brain and ner­vous system. NCVs eval­uate electrical potentials from peripheral nerves. These tests enable you to identify peripheral nerve dysfunction by measuring the conduction of the nerve pathways. Nerve functions are measured by recording the action potentials, both motor and sensory, and the amount of time it takes for the nerve to respond. An action potential is the sequential, elec­trochemical polarization and depolar­ization that travels across the mem­brane of a nerve cell in response to stimulation. SSEPs are performed to evaluate the sensory nervous system and analyze the function of the nerve pathways. They enable you to study the function of the spinal cord and nerves in the extremities by testing the pathways from the nerves in the extremities traveling to the brain. DEPs test areas supplied with nerve fibers by a single spinal nerve root, and are effective in documenting injuries and substantiating further treatment in cases with negative/mini­mal disc bulges on MRI and CT scans. Spinal Ultrasound uses high frequency sound waves to image the body and to evaluate and document the differentia­tion of soft tissue. This test provides useful information in identifying signs of inflammation in the facets, nerve roots, tendons, ligaments, and muscles. These neuroskeletal diagnostic tests play an important role in the diagnosis of many neuromuscular disorders. Additionally, these tests are a valuable tool you can employ to guide your treatment programs, pinpoint prob­lems, provide objective documenta­tion, and more accurately diagnose pathology. One of" the greatest misconceptions about ordering neuroskeletal diagnos­tic tests is that "a patient must have full-blown radicular symptoms" in order to provide the medical necessity required for testing. It's true that, if a patient has radicular symptoms, you have an adequate indication to justify ordering a diagnostic test. But, radi-culitis is not the only symptom for which diagnostic testing is indicated. Some others are Carpal Tunnel, Tarsal Tunnel, Thoracic Outlet Syndrome, Brachial Plexus Injury, Neuropathy, Lumbosacral Plexus Injury, Extremity Pain. Nerve Entrapment, Nerve Root Irritation, Extremity Numbness/Tin­gling, Discopathy, Herniated Disc, etc.... Additional indications include: Patient is not responding to care as expected Subjective complaints are evident, but objective findings are not supportive.... Evaluation is necessary to substantiate the need for continued care Effectiveness of treatment program needs to be measured. As you can see, these symptoms and indi­cations are far more diverse than ordering neuromuscular diagnostic-testing only for patients with radicular symptoms. Okay, you know you should be uti­lizing neuromuscular diagnostic test­ing as a tool to better diagnose and treat your patients. You know what these tests are and their purposes. You also know why you should order these tests. The next question is, "When do I order these tests'?". Let's take a look at the next new Continued Page 38 ...front patient walking into your clinic. Through your thorough examination on that patient's first visit, you docu­ment that the patient shows some of the symptoms/indications listed above. Do you order neuromuscular diagnos­tic testing at this point? No! You must first implement a conservative treatment program that the patient will follow over the next two-to-three weeks. You might ask, "If the patient fits the clinical criteria, why wouldn't I order these tests immediately?" The answer is. because you're a doctor. After all, with your God-given talent, your knowledge, and all of your years of studying, and practicing, you have the power to heal; so, let's give that a chance first. You will come to realize that, in many cases, your patients will respond to the treat­ment program that you have developed for them without diagnostic testing. Immediately ordering diagnostic testing on your patients is consid­ered over utilization and is unneces­sary. These tests are a tool, not a crutch. Diagnostic testing is a component of your treatment protocol, and should be implemented at the proper times tor the proper reasons. A fish­erman doesn't use a harpoon to catch a tiny minnow. The same concept applies to diagnostic testing. You must keep this point in mind when ordering these tests. However, in those cases where you're not satisfied with the recovery response, and the patient's symptoms persist, you should serious­ly consider ordering the appropriate diagnostic tests. When you decide to order a test, you must thoroughly doc­ument your decision in your notes throughout the entire process. Once you have received the results of the tests, you should adjust your treatment program according to the findings, and, again, be sure to document this change in your notes. There are a couple options available to you as to where neuroskeletal diag­nostic tests are performed. First, you can refer your patients out to a local neurologist or physiatrist and have him or her perform the tests. This scenario has its downside. If you do not have a strong relationship with the neurolo­gist, or physiatrist, then you run the risk of losing the patients you're refer­ring out. I don't have to tell you of the view held by many medical doctors concerning chiropractors and their role in patient care. When you refer your tests out. your patients will be tested in unfamiliar surroundings, making it uncomfortable for them to go through this required process. When you refer out, you risk losing control of your patients' care. I can't emphasize enough how important it is that your patients have positive experiences when it comes to their decision to fol­low your guidance as their physician. Remember, your patients are the key to a wonderful source of referrals for your practice, so it is imperative that their experience with you and your care is an excellent one. Finally, you are not generating revenue for your practice by referring your patients out. Although this is not the prima­ry reason for ordering neuromuscu-lar diagnostic testing, you are a busi­nessman, as well as a doctor. The decisions that you make in your clinic should be both for the good of your patients, as well as the success of your practice. A second option is to perform these tests in your clinic. This scenario offers a significantly superior approach, as compared to referring out. By performing these tests on-site, you expand the scope of your practice, and retain control of your patients. Your patients are tested in the familiar surroundings of your clinic, and you are able to generate additional revenue for your practice. Don't worry, you don't have to go out and spend tens of thousands of dollars in equipment, hire a full-time Board Certified Technician for S40K-S50K per year, and hire a Board Certified Neurologist for $15OK-$25()K per year. Although, it could be a viable option, if you have the patient flow of a small hospital. You can provide these services on-site by seeking out a qualified, ethical, and professional diagnostics company to assist you with your needs. There are many legal issues that you must be aware of if you decide to use a diagnostic testing company to perform your neuromuscular diagnostic testing, or if you decide to perform the tests on-site on your own. I cannot possibly go into all of them in this article, but I will be dis­cussing all of these issues in-depth in future articles. I will review a few of the issues you must be aware of when seeking out a diagnostics company or attempting to test on your own. The method of payment for your technical staff is highly regulated by the Federal Government. It is illegal to pay for a technician's services by the patient, by the hour, by the day, or by the nerve. Also, technicians must be board certified to perform a number of neuromuscular diagnostic tests. Board certification means that the technician has passed the National Boards provided by the American Association of Electroneurodiagnostic Technicians (AAETj. Attending a weekend course on nerve con­duction velocities does not qualify for board certification. Although weekend courses can play an important role in the training of a technician, it does not come close to qualifying as board certification. It takes years of experience and months of studying to pass the extremely challenging certifi­cation examination. Another pitfall you might encounter will occur if your billing is above rea­sonable and customary for diagnostic procedures. Your fees should be on the lower end of the fee schedule. You should also determine what amount the diagnostics company is billing out for their services. Their fees should also be on the lower end of the fee sched­ule. There is nothing worse than hav­ing an irate patient walk into your office with an Explanation of Benefits for thousands of dollars that their insurance company was billed by your diagnostics company. That's a good Continued Page 41 )IAGNOSTIC$ ...from Page 3 way to lose good patients fast! Also, the insurance industry doesn't look kindly upon physicians or compa­nies who abuse the system through unnecessary testing or ridiculously high billings. Leave greed at the door—this means for both you and the diagnostics company you're dealing with. Remember, the number one reason for performing these tests is to use them as tools to help diagnose, help treat, and help you to become the best doctor you can be. Chiropractic is very near and dear to me. and my desire is to assist the industry in as many ways as possible. It saddens me when I see good doctors around the country go down the wrong path or those who are not properly making use of the valuable tools that are at their disposal. Knowledge is one of the most important assets we have, so let's use that knowledge to our advantage and strengthen chiro­practic. If you wish to contact me for more information, I will be happy to discuss any legal issues surrounding diagnostic testing, or if you need assis­tance with either choosing the proper company to work with, or evaluating a company that you are currently work­ing with, please call me at (800) 848-8910 or email me at [email protected]. You can also visit our web­site at www.adv-diaii.com.